Dysphagia education from the sdx scope squad, experts with a passion for liberalized diets

Differentiating a Chonic Cough: Case Study of a Patient with COPD

Mrs. M had been on a modified diet texture at her nursing home since her admission from the acute care hospital last week. She had eaten regular foods with thin liquids her whole life. Her primary diagnosis was exacerbation of COPD and a sensation of “globus” or a “lump in her throat.” She was conservatively downgraded at bedside by the hospital SLP to nectar liquids and moist fork-mashable foods with sides of extra gravies and sauces due. She was restricted from thin liquids due to a suspicious chronic cough that was “concerning for possible aspiration.”

Her acute stay was too short to complete an instrumental dysphagia exam before hospital discharge. She was sent to a SNF for rehab on the modified diet recommend by the hospital SLP and sure enough, she started to refuse most meals. The facility SLP noted that even though she was drinking nectar, she was still coughing intermittently when she ate, and also coughing even when she wasn’t eating. The facility SLP requested a FEES in order to get to the bottom of the suspicious chronic cough and her physician agreed and ordered the exam.

SDX arrived on-site the next day. Upon scoping Mrs. M, the FEES exam revealed severe signs and symptoms of laryngopharyngeal reflux (LPR). She scored above an 11 (!!!) on the Reflux Finding Score which is indicative of such significant LPR that an ENT and or GI consult is indicated. She had severe edema and erythema to her arytenoid/interarytenoid space as well as bilateral vocal fold edema. She was deemed appropriate for thin liquids and a soft chopped diet texture with sides of gravies and sauces on the side to alleviate the discomfort in the lower pharynx. Her cough was not related to food or liquid aspiration after all. Mrs. M was seen for outpatient GI as well as ENT consultations and was placed upon an aggressive short-term PPI (proton pump inhibitor) BID and an anti-reflux regiment. Pulmonary was also consulted and indicated that there was some suspected backflow of reflux into the upper airway, potentially exacerbating some of her overall lung health issues.

Mrs. M continued to rehabilitate at the SNF prior to being ready to return home with family support. A second FEES prior to her discharge home was ordered and completed. The results of this repeat FEES only 4 weeks after the initial FEES revealed decreased respiratory incoordination, as the exacerbation of COPD had resolved, plus a decrease in laryngeal edema and erythema at the arytenoid/interarytenoid space. She reported easier transit of boluses and the chronic cough she had for many years had finally subsided with the LPR treatment. She was ready for diet advancement since she had successfully regained coordination of her swallow-breathe cycle.

If Mrs. M hadn’t been seen on a FEES, her issues including LPR and chronic cough would have resulted in an unnecessarily restricted diet. A FEES is your best tool for viewing the glottis and top of the esophagus and airway over longer periods of time, in color and in real-time. It is the ideal instrumental exam for patients with COPD and chronic cough issues of questionable etiology. Mrs. M returned home on a regular diet texture and will continue to see her specialists to wean reflux medications if/when indicated and to provide ongoing support for her lung health. See the FEES difference with SDX!